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The Report

The full analysis and sources behind the grade.

At a glance

ItemFinding
BodyOffice of the Inspector of Custodial Services, Western Australia (OICS)
TypeNot a regulator. An independent inspectorate: it inspects prisons, youth detention centres, court custody centres and prescribed lock-ups, reviews custodial services and reports to the WA Parliament. It cannot direct the Department of Justice, enforce standards or resolve individual complaints. It is in scope because its role is to hold the custodial system to account
Office holderEamon Ryan, Inspector since 4 May 2019, reappointed May 2024 (AR 2024-25 p 9). Jane Higgins appointed acting Inspector for eight months from 13 July 2026 while Mr Ryan takes leave before retiring on 20 November 2026 (oics.wa.gov.au, New Acting Inspector)
Enabling lawInspector of Custodial Services Act 2003 (WA), current version 02-a0-04, in force from 13 May 2016; no later version is listed (legislation.wa.gov.au, read 26 October 2026). The Act has no objects clause
Report under reviewAnnual Report 2024-25 (signed 19 September 2025; released 11 November 2025). The 2025-26 annual report was not yet on the OICS website on 26 October 2026; recent reports have been released in early November
Record examinedAnnual reports 2015-16 to 2024-25; the Act; WA Budget Statements 2026-27 (Division 32); 44 inspection reports (Reports 126 to 171) and their published key dates; the 2026 Show Cause Notice report; review list; media release list; OICS web pages read 26 October 2026
Money and staff, 2024-25Total cost of services $4.194m; service appropriation $3.927m; deficit $0.206m; 19.8 FTE (AR 2024-25 pp 36, 56)
Output, 2024-2511 reports tabled (7 inspections, 4 reviews) against a target of 9; 115 recommendations, 86% accepted "to some level"; 78 liaison visits (80 in the narrative); 91 Independent Visitor reports against a target of 150 (AR 2024-25 pp 13, 15, 18, 50-51)
Proposed overall gradeB
Short reasonA small office (about 19 staff, about $4.2m a year) that inspects every facility, publishes every report with the Department's response, and uses its strongest power, the show cause notice, when conditions call for it: four times since 2017, each time on grounds that included suspected degrading or cruel, inhuman or degrading treatment. Its weaknesses are its own: on its published key dates, 12 of 30 inspection intervals since 2019 ran past the three-year statutory limit and 9 ran more than a month past it (calc), including about 9.5 months for Banksia Hill and Unit 18; reports took a median of almost a year to reach the public in 2023-2025, mostly in its own drafting; and it does not report against the three-year obligation, implementation of its recommendations, or what happens to the issues people in custody raise

The grade follows the six criteria settled for Regulator Review on 11 October 2026. Section 12 sets out each criterion, its grade and the reasoning.

1. What the body is for

1.1 What the Act says

The Inspector of Custodial Services Act 2003 has no objects clause. Its purpose comes from the functions it gives the Inspector.

  • Mandatory inspection: "At least once every 3 years the Inspector is to inspect each – (a) prison; and (b) detention centre; and (c) court custody centre; and (d) lock-up" (s 19). The Inspector "is to prepare an inspection report on his or her findings in relation to each inspection under section 19" (s 20(1)).
  • Occasional inspections and reviews of custodial services, including the treatment of particular prisoners or detainees (ss 21-22; s 22 was amended in 2011).
  • Independence: "Except as provided in this section, the Inspector is not subject to direction by the Minister or any other person in the performance of the Inspector's functions" (s 17(1)). The Minister may direct an inspection or review (s 17(2)); the text of any direction must be in the annual report (s 17(4)).
  • Access: "free and unfettered access" to prisons, detention centres, court custody centres, people in custody, staff and the Department's documents (ss 28-30). Hindering access is an offence with a $20,000 penalty (s 32).
  • Show cause notices: if the Inspector suspects on reasonable grounds a serious risk to the safety, care or welfare of a person in custody, or that a person "is being, or has been, subjected to cruel, inhuman or degrading treatment", the Inspector may require the chief executive to show cause why the matter should not be referred to the Minister (s 33A, inserted 2011, in force 18 January 2012).
  • Reporting: an annual report to Parliament by 30 September, including "a list of the places referred to in section 19 that have been inspected since the preceding 30 June" and "a list of the places … that are proposed to be inspected in the period up to the next 30 June" (s 33(1), (2)(d), (2)(e)). Inspection reports, and any review reports the Inspector chooses to table, are held by the Speaker and the President and laid before Parliament "not before 30 days after the document is delivered" (s 35(1)).
  • Complaints: "it is not a function of the Inspector to deal with" an individual complaint except to refer it or to consider it within an inspection or review (s 26(2)).

1.2 What the OICS says it is for

"Our purpose is to provide independent oversight of custodial facilities and services in Western Australia" (AR 2024-25 p 49). Its vision is "To promote humanity and decency in custodial facilities and services throughout Western Australia" (AR 2024-25 p 10). Its single outcome in the State budget is that "The Parliament, Minister and other stakeholders are informed on the performance of custodial services" (Budget Statements 2026-27 p 467).

The OICS describes its own inspection duty this way: "Under sections 19-20 of the Inspector of Custodial Services Act 2003 (the Act) we must inspect and report to Parliament at least once every three years" on 17 prisons, five work camps, youth detention centres, all court custody centres and prescribed police lock-ups (oics.wa.gov.au, What we do, updated 28 August 2026).

1.3 Who it serves

Parliament first; it reports directly to both Houses and sends exit debriefs to the Legislative Council Standing Committee on Public Administration (AR 2024-25 p 22). It also manages the Independent Visitor Service, volunteers appointed by the Minister on the Inspector's advice who visit facilities, hear concerns from people in custody and report to the Office (AR 2024-25 p 15).

1.4 Who holds it to account

  • Parliament, through the annual report and two committees: the Legislative Assembly Community Development and Justice Committee and the Legislative Council Public Administration Committee (AR 2024-25 p 48).
  • The Auditor General audits the financial statements, controls and key performance indicators each year. For 2024-25 all three opinions were unqualified, and the KPIs were found "relevant and appropriate" (AR 2024-25 pp 43-47).
  • "The Office is exempt from the Freedom of Information Act 1992 and the Parliamentary Commissioner Act 1971" (AR 2024-25 p 35). The WA Ombudsman therefore cannot investigate its administration. These are features of the law and are not held against the OICS.
  • No parliamentary committee report or Auditor General performance audit examining the OICS's own performance was found.

1.5 What it is not

It is not a complaints body and does not investigate criminal matters (oics.wa.gov.au, What we do). It was designated in 2019 as a National Preventive Mechanism under OPCAT for justice-related places of detention, which would extend its remit to about 156 police lock-ups, but "legislation, and resourcing to commence this work has not progressed" (AR 2024-25 p 24). The current version of the Act dates from 13 May 2016. That is the government's and Parliament's responsibility, not the Inspector's.

2. The test

The core test is the gap between what the body is meant to do and what the record shows it does. For a custodial inspectorate the test has five parts:

  1. Does it inspect every place the law requires, at least every three years, and report to Parliament?
  2. Do its reports reach Parliament and the public while they still matter?
  3. Does it act, using its strongest powers, when conditions call for it?
  4. Do its findings change anything, and does it track whether they do?
  5. Does it report honestly about its own performance?

A distinction runs through this report. Many of the failures the OICS reports are failures of the Department of Justice or of government: overcrowding, staff shortages, lockdowns, slow responses to draft reports, and recommendations accepted but not acted on. They are recorded here because they shape the OICS's results, but they are not held against it. The grade is about what the Inspector controls.

3. The core job: inspecting every place every three years

3.1 Output

The OICS has tabled between 8 and 14 reports a year since 2013-14, against a standing target of 9.

YearReports tabledRecommendationsAccepted (any level)Liaison visitsIV reports
2013-141415386%101177
2014-151118091%96165
2015-161010080%86174
2016-1799689%102162
2017-181116490%98135
2018-191010280%70125
2019-2085777%6399
2020-2189187%6497
2021-221113070%55142
2022-2399178%78163
2023-2498883%72121
2024-251111586%7891
2025-26 (estimated actual)n/a8988%n/an/a

Sources: AR 2015-16 p 28 (PDF p 30); AR 2017-18 pp 26-27; AR 2019-20 pp 25-26; AR 2020-21 pp 34-36; AR 2024-25 pp 50-51; Budget Statements 2026-27 p 467. Eleven reports were published between 1 July 2025 and 30 June 2026 according to the OICS website listing (Reports 162 to 168 and four review reports) (calc).

3.2 Is the three-year cycle met?

The annual reports do not say. They describe the cycle ("Inspections operate on a mandated three-year cycle", AR 2024-25 p 51), and the 2019-20 and 2020-21 reports said "we have still met our statutory obligations for inspection reports" (AR 2019-20 p 26; AR 2020-21 p 35). No report examined lists each facility with its last and next inspection date or says whether any has gone past three years.

Every OICS inspection report since about 2019 publishes its key dates, including the start of the on-site inspection. Regulator Review used those dates to measure the gap between successive on-site inspections of each facility. The Act does not define "inspect". The OICS's own annual report says each prison, youth detention centre, court custody centre and prescribed lockup "is required to be subjected to a full inspection" on the three-year cycle (AR 2024-25 p 51). This analysis treats the start of a full on-site inspection as the inspection date, and counts intervals that began in 2019 or later. Liaison visits, follow-up reviews and monitoring are not counted.

FacilityPrevious on-site startNext on-site startGapBeyond 3 years (calc)
Acacia10 Nov 2021 (Rep 146)14 Oct 2024 (Rep 163)2.9 yrsNo
Albany7 Feb 2021 (Rep 138)4 Feb 2024 (Rep 157)3.0 yrsNo
Bandyup20 May 2020 (Rep 131)8 Sep 2023 (Rep 156)3.3 yrs111 days
Bandyup8 Sep 2023 (Rep 156)July 2026 (announced)2.8 yrsNo
Banksia Hill16 Sep 2020 (Rep 135)6 Feb 2023 (Rep 148)2.4 yrsNo
Banksia Hill and Unit 186 Feb 2023 (Rep 148)23 Nov 2026 (scheduled)3.8 yrs290 days
Boronia23 May 2021 (Rep 139)24 Mar 2024 (Rep 161)2.8 yrsNo
Broome21 Jul 2019 (Rep 126)15 May 2022 (Rep 149)2.8 yrsNo
Broome15 May 2022 (Rep 149)18 May 2025 (Rep 166)3.0 yrs3 days
Bunbury22 Jul 2020 (Rep 134)23 Jul 2023 (Rep 153)3.0 yrs1 day
Bunbury23 Jul 2023 (Rep 153)9 Feb 2026 (Rep 170)2.6 yrsNo
Casuarina8 Sep 2019 (Rep 129)5 Sep 2022 (Rep 150)3.0 yrsNo
Casuarina5 Sep 2022 (Rep 150)13 Oct 2025 (Rep 168)3.1 yrs38 days
Court custody centres8 Dec 2020 (Rep 143)31 Aug 2023 (Rep 160)2.7 yrsNo
Eastern Goldfields9 Feb 2020 (Rep 132)2 Apr 2023 (Rep 152)3.1 yrs52 days
Eastern Goldfields2 Apr 2023 (Rep 152)May 2026 (announced)3.1 yrsat least 29 days
Greenough19 Sep 2021 (Rep 142)15 Jul 2024 (Rep 159)2.8 yrsNo
Hakea21 Jul 2021 (Rep 140)6 May 2024 (Rep 158)2.8 yrsNo
Karnet18 Mar 2019 (Rep 127)17 Jul 2022 (Rep 151)3.3 yrs121 days
Karnet17 Jul 2022 (Rep 151)18 Nov 2024 (Rep 164)2.3 yrsNo
Melaleuca15 Nov 2020 (Rep 136)11 Nov 2023 (Rep 155)3.0 yrsNo
Melaleuca11 Nov 2023 (Rep 155)23 Mar 2026 (Rep 171)2.4 yrsNo
Pardelup16 Jan 2022 (Rep 144)18 Nov 2024 (Rep 164)2.8 yrsNo
Roebourne19 May 2019 (Rep 128)13 Mar 2022 (Rep 145)2.8 yrsNo
Roebourne13 Mar 2022 (Rep 145)24 Nov 2025 (Rep 169)3.7 yrs256 days
Wandoo9 Nov 2019 (Rep 130)7 Nov 2022 (Rep 147)3.0 yrsNo
Wandoo7 Nov 2022 (Rep 147)20 Jul 2025 (Rep 167)2.7 yrsNo
West Kimberley6 Apr 2020, virtual (Rep 133)28 May 2023 (Rep 154)3.1 yrs52 days
West Kimberley28 May 2023 (Rep 154)September 2026 (announced)3.3 yrsabout 96 days or more
Wooroloo28 Mar 2021 (Rep 137)18 Nov 2024 (Rep 164)3.6 yrs235 days

Sources: key dates pages of each report cited (page references in the sources checklist); Report 148 p 38; oics.wa.gov.au Current work (updated 22 September 2026) for Banksia Hill and Unit 18 ("scheduled to occur from 23 November to 2 December 2026"); Announced Inspection of West Kimberley Regional Prison ("in September 2026"; exact start date not published); announced inspections of Eastern Goldfields Regional Prison ("in May 2026") and Bandyup Women's Prison ("in July 2026"), exact start dates not published; Report 135 key dates (16 September 2020).

Of 30 intervals, 18 were within three years and 12 were not (calc). Two overran by a day or a few days (Broome 2022-2025, Bunbury 2020-2023). Nine overran by more than a month: Bandyup, Banksia Hill and Unit 18, Casuarina, Eastern Goldfields (2020-2023), Karnet, Roebourne, West Kimberley (twice) and Wooroloo. The Eastern Goldfields 2023-2026 interval overran by at least 29 days; the exact May 2026 start date is not published. Three overran by more than seven months: Banksia Hill and Unit 18, Roebourne and Wooroloo. Some of the earlier overruns fall in the COVID-19 period, when the OICS reported having to suspend its May 2022 Broome inspection part-way (AR 2021-22 p 4) and conducted the 2020 West Kimberley inspection virtually.

The OICS's own forward plans show most of the longer overruns were known in advance. Section 33(2)(e) requires each annual report to list the places to be inspected in the coming year, and the OICS has done so each year from 2021-22 to 2024-25 (AR 2021-22 p 40; AR 2022-23 p 31; AR 2023-24 p 33; AR 2024-25 p 21). Five facilities that fell due in a year were left off that year's list: Bandyup (due 20 May 2023, absent from the 2022-23 list), Wooroloo (due 28 March 2024, absent from the 2023-24 list), Roebourne (due 13 March 2025, absent from the 2024-25 list), and Banksia Hill and Unit 18 (due 6 February 2026) and West Kimberley (due 28 May 2026), both absent from the 2025-26 list (calc). Others were listed for dates already past the three-year mark: Karnet (July 2022), Casuarina (October 2025) and Eastern Goldfields (May 2026) (calc). The 2025-26 list was Wandoo (July 2025), Casuarina (October 2025), Roebourne (November 2025), Bunbury (February 2026), Melaleuca (March 2026) and Eastern Goldfields (May 2026) (AR 2024-25 p 21).

Banksia Hill and Unit 18 were not unwatched in that period. The OICS began a follow-up review in May 2024, published in December 2024 as "Review of youth custody: Follow-up to 2023 Inspection (Part Two)", made "12 visits to the youth facilities" in 2023-24 and analysed out-of-cell hours, staffing and incidents daily and weekly (OICS media release, Annual Report 2023-24, 6 November 2024). It plans at least five liaison visits a year to each youth site (AR 2024-25 p 13). Whether that monitoring satisfies s 19 is a question of interpretation. The OICS itself calls the December 2024 report a review, and it has not explained publicly why a full inspection was scheduled for late 2026.

Regulator Review's assessment: the OICS inspects every place in its jurisdiction and reports on each one, and the inspections are thorough. But on its own published dates, 12 of 30 inspection cycles since 2019 ran past the three-year limit, nine of them by more than a month (calc), most of them visible in advance in its own forward plans, the longest at the state's only youth detention centres during a period the OICS itself called a crisis, and the OICS does not report this.

4. Timeliness: how long reports take to reach Parliament and the public

4.1 What the OICS says

Each annual report from 2015-16 to 2020-21 carries the same footnote: "The average time taken from the start of an inspection to the production and lodgement of a report in Parliament is between six and nine months depending upon the complexity of the facility or service" (AR 2015-16 p 28; AR 2017-18 p 27; AR 2019-20 p 26; AR 2020-21 p 36). The 2024-25 version reads "from the start of an inspection or review project" (AR 2024-25 p 51 fn 2). The performance indicator pages of the 2021-22 to 2023-24 reports are images in the PDFs and were not checked for the footnote.

In 2023-24 the Inspector wrote that some work "has taken longer than we might have liked", citing finite resources, the complexity of the work and the Department's slow responses: "For the nine reports we published this year, none of the responses from the Department were received within the five-week period and the average time for a response was 11.3 weeks" (AR 2023-24 p 3). The Act's 30-day embargo adds at least a month (s 35; AR 2024-25 p 12).

4.2 What the key dates show

ReportsNumberMedian: end of on-site to draft sent to Department (OICS)Median: draft to Department response (Department)Median: end of on-site to public release
147 to 161 (released June 2023 to June 2025)1434.8 weeks9.1 weeks12.7 months
163 to 171 (released August 2025 to October 2026)920.0 weeks7.3 weeks8.0 months

All figures (calc) from the key dates in each report and the OICS website release dates. Report 162, a follow-up based on visits rather than a full inspection, is excluded, as is Report 148 (Part One of a split report, released 8 June 2023, with no Department response date). Report 165 (work camps) is included in the second group. Three reports (147, 149, 157) give no Department response date and are excluded from the Department column.

  • Of 20 reports with a Department response date, 19 responses took longer than the five weeks agreed in the Memorandum of Understanding (calc). That is the Department's failure.
  • But the larger delay was the OICS's own. For reports released between mid-2023 and mid-2025, the OICS took a median of about eight months from the end of fieldwork to send a draft to the Department. The longest were Report 160, Court Custody Centres (58 weeks), Report 156, Bandyup (51 weeks), Report 161, Boronia (48 weeks) and Report 149, Broome (46 weeks) (calc).
  • Several reports reached the public more than a year after the inspection: Broome 149 (14.2 months), Casuarina 150 (13.2), Karnet 151 (14.6), Bandyup 156 (16.3), Court Custody Centres 160 (17.0) and Boronia 161 (14.7) (calc).
  • After a review of its operating methodology in 2024-25, which included "Revised process mapping to strengthen planning and improve timeliness of reporting" (AR 2024-25 p 17), the OICS's drafting time fell to a median of 20 weeks and the total to about eight months (calc). That is a real improvement.

The six-to-nine-month footnote is not consistent with the 2023-2025 record, even measured from the end of fieldwork rather than "the start of an inspection" (calc). No measured figure for report timeliness appears in the annual reports.

4.3 Report 148 and the embargo

The Act's 30-day embargo is a matter for Parliament. The OICS has said so plainly: "Other Western Australian statutory officers do not face such a long embargo" (AR 2024-25 p 12). Its media release for Report 148 noted the report "was laid before both Houses on 8 May 2023, one day prior to the most recent riot at Banksia Hill Detention Centre (9-10 May 2023)", and that it was split into two parts "In the public interest of speeding up our reporting" (OICS media release, Report 148, 8 June 2023).

Regulator Review's assessment: the Department's slow responses and the statutory embargo are real and are not the OICS's fault. But in 2023-2025 the OICS's own drafting was the largest single cause of delay. Its annual reports pointed to finite resources, workload, the Department's responses and the embargo, not to its own drafting time, and the six-to-nine-month footnote has been repeated without measurement. The improvement since mid-2025 is substantial and is credited.

5. Recommendations: accepted, and then what?

5.1 Acceptance

The only effectiveness KPI is "The extent to which the Department of Justice and, where relevant, other agencies accept recommendations contained in reports" (AR 2024-25 p 50). "Accepted" includes "supported", "supported in principle" (where "there are practical impediments to its implementation", for example the need for "additional resources") and "supported as current practice or project" (AR 2024-25 p 50). In 2024-25, 99 of 115 recommendations (86%) were supported at one of those levels, 7 were noted and 8 not supported (AR 2024-25 p 50). Acceptance was below the 80% target in 2019-20 (77%), 2021-22 (70%) and 2022-23 (78%) (table, section 3.1).

The 2015-16 annual report said "only 15 per cent of our recommendations received unqualified support", and that "the fact a recommendation is rejected does not make it a bad recommendation" (AR 2015-16 p 17). No later annual report examined gives the unqualified share.

5.2 Implementation

The OICS does not publish an implementation rate for its own recommendations. Inspection reports discuss earlier findings, and the West Kimberley inspection "will assess progress made on the previous recommendations" (oics.wa.gov.au, Announced Inspection of West Kimberley Regional Prison), but no aggregate figure was found.

What the OICS has published about implementation is damning for the Department:

  • In a 2022 review the OICS noted "the Department had closed off all the recommendations as 'completed'. This is of considerable concern to us, suggesting that nothing additional would be done in order to meet the spirit and intent of our recommendations" (AR 2021-22 p 35).
  • Its 2023 directed review of the Department's response to the 35 coronial recommendations made to it on deaths in custody between 2017 and 2021 (it tested a sample of 10) found "the Department frequently closed recommendations without full implementation" (Directed Review into the Department of Justice's performance in responding to recommendations arising from coronial inquiries into deaths in custody, April 2023, Conclusion).
  • Strategic recommendations directed to government are "noted" rather than answered. Report 162 recommended "The Government should undertake a formal inquiry into the operations of Hakea Prison"; the Department "only 'noted' this recommendation, advising they could not respond as the recommendation was directed to the Government" (Report 162, July 2025, p iv). In April 2026 the Inspector wrote that neither this nor Report 158's taskforce recommendation "has been implemented to the size or scale necessary to achieve the systemic reforms required" (Show Cause Notice report, 2026, p v).

Regulator Review's assessment: these are the Department's and the government's failures, not the Inspector's. But an inspectorate whose only effectiveness measure is acceptance "to some level", and which has shown the Department closes recommendations without doing them, has the evidence to know that acceptance is a weak measure. It does not report implementation.

6. Willingness to use its powers

The show cause notice is the strongest formal tool the Act gives the Inspector. Its use is on the public record:

DateFacilityOutcome
24 February 2017Banksia Hill (incident of 31 December 2016)First use of the power. The OICS had "reasonable grounds to believe the boy had been subjected to degrading treatment" when officers aimed laser sights at a boy on the roof; not referred after the Department took further action (AR 2016-17 pp 19-20)
17 December 2021Banksia Hill Intensive Support UnitInspector suspected detainees were "being subjected to cruel, inhuman or degrading treatment in the ISU"; referred to the Minister, the first referral (AR 2021-22 pp 4, 43)
27 May 2024Hakea PrisonInspector suspected prisoners were subjected to "cruel, inhuman, or degrading treatment"; referred to the Minister 14 June 2024 (AR 2023-24 pp 37-38)
11 March 2026Hakea, Casuarina and MelaleucaSame grounds; referred to the Minister 8 April 2026; report tabled 9 June 2026 (Show Cause Notice report pp v-vi)

The 2026 report stated: "Almost two years after the Show Cause Notice was issued in respect of Hakea, conditions have not materially improved and, in fact, similar conditions are now evident in both Melaleuca and Casuarina" (p v). The Inspector's media release said: "This is no longer a problem confined to a single facility – it reflects a systemic failure across multiple prisons" (OICS media release, 9 June 2026).

Other uses of its powers:

  • An unscheduled inspection of the Banksia Hill Intensive Support Unit in December 2021, "prompted by significant concerns" about self-harm, suicide attempts and assaults (AR 2021-22 p 4).
  • An unannounced night visit to Hakea in February 2025 to assess staffing (AR 2024-25 p 23).
  • Plain findings: Report 158 (April 2025) found living conditions at Hakea "substandard and inhumane" (Report 158, contents and chapter 3, p 13).
  • A media release with each inspection and review report released since at least December 2024 (OICS media release listing).

Regulator Review's assessment: the OICS uses the powers it has, publicly and repeatedly, and reports its findings in plain terms. The power ends at referral to the Minister; what happens next is for government.

7. Youth detention: Banksia Hill and Unit 18

  • After its February 2023 inspection the OICS concluded "Youth custody in Western Australia is in acute crisis, and there is no immediate solution" (Report 148, Conclusion page, oics.wa.gov.au). The Inspector said "Every element of Banksia Hill was failing, often through no fault of its own or the efforts of staff" (OICS media release, Report 148, 8 June 2023).
  • Cleveland Dodd, a young Aboriginal person, died by suicide in October 2023 while held in Unit 18; a second young person "took his life in Banksia Hill Detention Centre on 29 August 2024" (AR 2023-24 p 2). The National Indigenous Times reported that Cleveland was 16 and was found unresponsive in his cell on 12 October 2023 (National Indigenous Times, 8 December 2025).
  • The Inspector wrote: "for over ten years, reports by this Office highlighted significant issues and problems around how the state cares for and manages young people in detention in Western Australia. Publication of these issues ultimately did not lead to the systemic reforms necessary to prevent such a tragic outcome." And: "We all must accept some level of responsibility for these outcomes, and I include myself in this. I have constantly asked myself whether we could have done more or advocated harder for change" (AR 2023-24 p 2).
  • In December 2024 the follow-up review found "green shoots" and improvements in time out of cell, education and health access (OICS media release, 19 December 2024).
  • On Unit 18 the OICS's position in 2025 was: "The majority opinion is that Unit 18 is not fit for purpose and ought to be closed. We share this view, but with one caveat, and that is only when it is safe to do so" (AR 2024-25 p 8).
  • The National Indigenous Times reported on 8 and 9 December 2025 that Coroner Philip Urquhart had delivered his findings, with 19 recommendations, including that Unit 18 be closed "as a matter of urgency" and that a special inquiry be held into how Unit 18 came to be. The findings themselves were not read for this report.
  • The next full inspection of both centres is scheduled for 23 November to 2 December 2026, about 3 years 9 months after the last (section 3.2).

Regulator Review's assessment: the OICS warned repeatedly and early about youth detention, and the failures it described were the Department's and the government's. It also monitored the centres intensively after 2023. Its full inspection cycle for the centres has nonetheless run well past the statutory three years.

8. Independent Visitors and people in custody

  • Independent Visitor (IV) reports fell from 177 (2013-14) to 91 (2024-25), against a target of 150 (section 3.1). The 2024-25 fall is explained by a new work health and safety policy requiring IVs to visit in pairs and submit one joint report (AR 2024-25 pp 15, 51-52).
  • IVs raised 2,154 items in 2021-22, over 800 in 2022-23, over 1,000 in 2023-24 and over 1,100 in 2024-25 (AR 2021-22 p 14; AR 2022-23 p 15; AR 2023-24 p 16; AR 2024-25 p 15). The OICS forwards relevant matters to the Department and follows up. It does not report how many matters were resolved, how long they took, or what the Department did.
  • The annual report says "This equates to less than 60% of our target" (AR 2024-25 p 18). 91 of 150 is 60.7% (calc).
  • The 2021-22 report said "we now have in excess of 40 IVs" (AR 2021-22 p 14); no number was found in the 2024-25 report.
  • The OICS receives letters and calls from people in custody, families and lawyers. In 2015-16 "we received 118 letters" (AR 2015-16 p 22). Later reports say only that it "regularly receive[s]" such contacts; 2024-25 says "The Office received correspondence" (AR 2024-25 p 40). No count has been published since 2015-16 in the reports examined.
  • Before each inspection, community members and service providers are invited to give feedback (oics.wa.gov.au, Our role; announcement of Banksia Hill and Unit 18 inspection).

Regulator Review's assessment: the OICS is not a complaints body, and the law says so. But the Independent Visitor Service is its own program, and over a thousand issues a year go into it with no published account of what comes out.

9. Systemic impact

The OICS's reports are consistently system-level: staffing, overcrowding, mental health, remand growth, Aboriginal people in custody, the use of force and confinement. Its reviews have covered smoking, dental care, protection prisoners, family violence supports, crisis care, non-custodial staffing shortages and workers' compensation (OICS review listing). Its current work includes a three-part series on remand, rehabilitation and parole (oics.wa.gov.au, Current work).

The evidence of impact is mixed, and mostly not in the Inspector's hands:

  • The adult prison population rose from 7,800 on 1 July 2024 to 8,475 on 30 June 2025, and "373 men and 33 women" were sleeping on cell floors on 30 June 2025 (AR 2024-25 p 26). The average daily population rose 37% between January 2023 and February 2026 (Show Cause Notice report p iv).
  • The Inspector credited improvements in youth custody after 2023 (section 7), and the Department released a Corrective Services Strategic Plan 2025-2030 (AR 2024-25 p 7).
  • Conditions at Hakea did not materially improve between the 2024 and 2026 show cause notices (section 6).

Regulator Review's assessment: the OICS identifies systemic problems accurately and early, and its work is widely cited in public debate. Its findings change things slowly, if at all, because the Department and government decide. The OICS's measurable contribution is limited by the absence of any implementation tracking of its own.

10. Money and resources

YearService appropriationTotal cost of servicesStaff
2015-16$3.570m$3.601mn/a
2017-18$3.544m$3.659m20 (staff profile total)
2018-19$3.590m$3.963m18 (staff profile total)
2020-21$3.522mn/an/a
2023-24$3.818m$3.892m19 FTE
2024-25$3.927m$4.194m19.8 FTE
2026-27 (budget)$4.186m$4.276m19 FTE

Sources: AR 2015-16 (PDF pp 44, 57); AR 2017-18 (PDF pp 42, 46); AR 2018-19 (PDF pp 40, 44; staff profile p 27); AR 2020-21 (PDF p 51); AR 2024-25 pp 36, 56; Budget Statements 2026-27 pp 466, 468. Staff counts are not on the same basis across years: the 2017-18 and 2018-19 totals mix full-time staff with part-time staff counted on an FTE basis.

  • Service appropriation rose about 10% in nominal terms between 2015-16 and 2024-25 (calc), before inflation.
  • In 2017-18 the OICS had "a 3.5 per cent budget cut" and lost a position (AR 2017-18 p 13). In 2019-20 the liaison visit target "dropped from 90 to 60 in response to budget cuts from prior years" (AR 2019-20 p 26).
  • In 2023-24 the Inspector wrote: "Over recent years we have not sought additional resources and instead tried to do more with less" (AR 2023-24 p 3).
  • The 2026-27 budget repeats that the OPCAT nomination "will extend the Office's jurisdiction and workload to include police lockups" but records no funding for it (Budget Statements 2026-27 p 466).

Regulator Review's assessment: the OICS is very small for its jurisdiction, and the OPCAT expansion has been left unfunded and unlegislated by government for seven years. The decision not to seek more resources, during a period of record prisoner numbers, was the Inspector's own, and may help explain the slipped inspection cycles and slow reports.

11. Transparency about itself

The OICS publishes a great deal. Every inspection and review report is on its website with the Department's response to each recommendation, an Inspector's overview and a media release. Each inspection report carries a dated timeline from announcement to tabling, which is what made sections 3 and 4 of this report possible. Its current work page gives expected tabling dates. Its KPIs are audited.

It also leaves out or blurs the measures that would show its own performance.

11.1 What is not published, or stopped being published

ItemStatusSource
Compliance with the s 19 three-year inspection cycle, facility by facilityNever published in the reports examined; statements that statutory obligations were "met" in 2019-20 and 2020-21 onlyAR 2019-20 p 26; AR 2020-21 p 35
Measured report timelinessNot measured; a six-to-nine-month footnote has been repeated since at least 2015-16AR 2015-16 p 28; AR 2024-25 p 51
Share of recommendations given unqualified supportLast published 2015-16 (15%)AR 2015-16 p 17
Implementation of its recommendationsNever published as a rateAR 2015-16 to AR 2024-25
Count of letters and contacts from people in custody and familiesLast published 2015-16 (118 letters)AR 2015-16 p 22
Outcomes of matters raised through Independent VisitorsNot published; only counts of items raisedAR 2024-25 p 15
Number of Independent Visitors"in excess of 40" in 2021-22; not found in 2024-25AR 2021-22 p 14

11.2 Changed bases and soft targets

  • Liaison visit target cut from 90 to 60 in 2019-20 "in response to budget cuts" (AR 2019-20 p 26).
  • Independent Visitor reports: from 2024 one joint report per paired visit, so the count is not comparable with earlier years (AR 2024-25 p 51 fn 3). The cost-per-report target was $4,000 for 2024-25 (AR 2024-25 p 51) and $8,000 for 2025-26 and 2026-27 (Budget Statements 2026-27 p 468). The 2024-25 result was $6,486.
  • The acceptance KPI counts "supported in principle" and "supported as current practice" as accepted (AR 2024-25 p 50).
  • The OICS website says "We visit most prisons at least four times each year, and the higher risk prisons and Banksia Hill Detention Centre at least six times a year" (What we do, updated 28 August 2026). The 2024-25 annual report says "We visit most facilities at least three times per year, and higher risk locations at least five times" (AR 2024-25 p 13). On the 2024-25 schedule, ten prisons had three visits or fewer (calc from AR 2024-25 p 13).

11.3 Inconsistencies

  • Liaison visits in 2024-25: "This year we conducted 80 liaison visits" (p 13); the KPI table shows 78 (p 51).
  • Independent Visitor reports: "less than 60% of our target" (p 18); 91 of 150 is 60.7% (calc).
  • Average cost per IV report 2024-25: $6,486 (AR 2024-25 p 51); $6,468 (Budget Statements 2026-27 p 468).

None of these changes the findings above. They are recorded as printed.

Regulator Review's assessment: on publishing its own work the OICS is among the most open bodies reviewed; the published timelines in each report are a model. On measuring and reporting its own performance it is weak: the one statutory duty most easily checked, the three-year cycle, is not reported against, and its timeliness claim is unmeasured.

12. Assessment and proposed grade

Findings of fact are in sections 1 to 11. This section is Regulator Review's assessment.

Scale used: A excellent; B good; C adequate; D poor; E failing; F not performing the function.

CriterionGradeReason
1. Doing the core job: inspecting every custodial facility at least every three years and reporting to ParliamentBEvery facility is inspected and reported on, thoroughly, with 8 to 14 reports a year against a target of 9. Held back because 12 of 30 inspection intervals since 2019 overran three years, 9 by more than a month (calc), including about 9.5 months for Banksia Hill and Unit 18, and its own forward plans left out five facilities as they fell due
2. Service to the people it is there forCParliament got reports a median 12.7 months after fieldwork in 2023-2025 (calc), mainly because of the OICS's own drafting time; now about 8 months. Independent Visitor reports well below target and outcomes of 1,100-plus issues unreported. The Department's late responses and the 30-day embargo are not held against it
3. Willingness to use its powersAShow cause notices in 2017, 2021, 2024 and 2026, the last three referred to the Minister, each on grounds that included suspected degrading or cruel, inhuman or degrading treatment; an unscheduled inspection and unannounced visits; plain, public findings
4. Systemic impactCAccurate, early, system-level findings and reviews, and real gains in youth custody after 2023. But its strategic recommendations are noted rather than acted on, conditions it condemned in 2024 had spread by 2026, and it does not measure implementation of its own recommendations
5. Transparency about itselfCPublishes every report, the Department's responses and dated timelines. But does not report against its three-year obligation, repeats an unmeasured timeliness claim, has not published a count of public contacts since 2015-16, reports no implementation or IV outcome data, and has a doubled IV cost-per-report target
6. AccountabilityBClean audit opinions on accounts, controls and KPIs; an Inspector who publicly accepted a share of responsibility for youth deaths; a methodology review that cut reporting time markedly. But its 2023-24 account of delay cited resources, workload and the Department's responses, not its own drafting time. The FOI and Ombudsman exemptions are features of the law and are not held against it

Proposed overall grade: B.

Reasoning. The criterion closest to the OICS's core job, inspecting every place of custody and reporting to Parliament, carries the most weight. The OICS does that job, with depth, plain findings and a full public record, on about $4.2 million a year and 19 staff. It uses its strongest power when the evidence calls for it, which is not true of most bodies Regulator Review has examined. That is why it is not C. It is not A because the statutory three-year cycle has slipped repeatedly and the OICS does not say so; because in 2023-2025 its own drafting, not only the Department and the embargo, kept reports from Parliament for close to a year; and because it measures acceptance, not implementation, and does not report what happens to the issues people in custody raise through its own visitors. The most serious failures in WA custody over this period, overcrowding, lockdowns, Unit 18 and deaths in custody, belong to the Department of Justice and the government. The OICS reported them.

What would change the grade:

  • Down to C: if the Banksia Hill and Unit 18 inspection does not start as scheduled in November 2026; further three-year overruns; a return to report times of a year or more; or a 2025-26 annual report that again omits any account of the three-year cycle.
  • Up to A: a published facility-by-facility table of last and next inspection dates against the three-year limit, with reasons for any overrun; measured report timeliness replacing the six-to-nine-month footnote; a published rate of implementation of its recommendations, tested in later inspections; and published outcomes for matters raised through Independent Visitors.

13. What is not known

  • The exact start date of the September 2026 West Kimberley inspection, and whether the scheduled Banksia Hill and Unit 18 inspection will proceed on 23 November 2026.
  • Whether the OICS regards the 2024 youth custody follow-up review, liaison visits or other monitoring as satisfying s 19 for Banksia Hill and Unit 18, or for any other facility. It has not said.
  • The exact on-site dates for the Eastern Goldfields inspection (announced for May 2026) and the Bandyup inspection (announced for July 2026); neither report had been released at 26 October 2026.
  • Inspection dates before 2019 were not checked, except where cited.
  • How many of its recommendations the Department has implemented. Not published.
  • How many letters, calls and approaches the OICS receives, and what becomes of them. Not published since 2015-16.
  • What happens to the matters Independent Visitors raise, and how many Independent Visitors there are now.
  • The 2025-26 annual report, not yet released at 26 October 2026.
  • The Coroner's findings in the Cleveland Dodd inquest were not read; the summary here relies on media reports. Whether the Coroner commented on the OICS is not known.
  • The financial statements in AR 2021-22, 2022-23 and 2023-24 are image-only in the PDFs and were not read; 2015-16 to 2020-21 and 2024-25 were read as text.
  • Whether the Minister has responded formally to the 2026 show cause referral or to the Show Cause Notice report's recommendation.
  • No WA parliamentary committee report examining the OICS's performance was found. One may exist.

14. Sources